Workshop Registration Form

Cisco Entrepreneur Institute

Starting a Business 7
May 15 – August 21, 2012
15 sessions: Every Tuesday evening 6-9pm
$ 600

Participant Information

Name:	Home Address:
Company Name	Home Phone:
Title	Mobile Phone:
Website:	Work Phone:
Education: Degree & Year	Email:
In which sector do you want to start or grow a business?
Please list any professional associations, groups, clubs, or organizations you belong to:

Preferred Social Networking Site: Click here to choose

Do you have access to an internet connection with a speed of at least 512 Kbps? Choose below.

English Proficiency:

Speaking: Click here to choose	Reading: Click here to choose	Writing: Click here to choose

Payment Details

Workshop Selection	Payment to be made:	Method of Payment:

Signature: ________________________________________ Date: _____________________

To reserve your place, please submit this form by fax or email no later than April 30.

Your registration will be complete upon finalizing the payment at AMIDEAST:

Bazerkan Bldg, 1st floor, Nijmeh Square, Riad El Solh St. Beirut Downtown

Telephone: +961 1 989901 ext: 234

Fax: +961 1 989901 ext: 100

Email: ajerab@amideast.org

Website: www.amideast.org/lebanon